CPT code for subacromial decompression w/o acromioplasty?
Dr. wants to bill 29826 but did not perform an acromioplasty. I've informed him we cannot bill 29826 without the acromioplasty. Below is his op report.
He was brought back to the operating room, placed supine on the operating room table, anesthesia was administered. He was properly padded, prepped, and draped. After pausing for safety, a #11 blade was used to make a posterior portal in the left shoulder. I entered the shoulder joint, looked around the shoulder, it looked normal. He had some minor labral disease, but nothing of significance. I went into subacromial space and then I created an accessory portal. I used a shaver to debride the subacromial bursa. I went over to the AC joint. I performed a capsulectomy. I then entered the AC joint. I then used a high-speed burr to resect about 9 to 10 mm of bone to allow for a gap of 1.4 cm, I measured with a spinal needle. I checked under multiple views to make sure I had proper resection margins. I removed any debris I could find, and I closed the portals with interrupted Prolene followed by sterile dressing and a sling. The patient was awoken from anesthesia, transferred to postanesthesia care unit stable with no complications.